Doctors

Getting the Best Care

Getting the Best Care

Whichever doctor you select, how you interact with him or her will have a big effect on the success of your care. Some suggestions:

Be sure your doctor takes a thorough medical history.

If you feel your doctor has not asked about something that might be important in diagnosing or treating you, volunteer the information. For example, if both of your parents had colon cancer, your dad had a heart attack at age 40, you recently had a bout with kidney stones, or you periodically feel very depressed, let the doctor know.

Find out about the tests your doctor proposes to do.

Ask your doctor what tests he or she will do and why. If you’re concerned about particular medical problems, ask if there are relevant tests and why they do or don’t make sense for you. Ask what each test will tell you that you don’t already know, how reliable it is, the risks and the costs, and whether the results are likely to make any real difference in treatment plans.

There’s a lot of debate in the medical field about which routine tests are worth doing for which population groups and how often. There are reasons not to perform tests: Some are unpleasant, some are costly, some pose risks of complications, and all can possibly indicate that you have a problem you really don’t have—leading to costly, unpleasant, and possibly dangerous treatment.

One solution to rein in costly, unnecessary, and possibly harmful medical care is educating doctors and patients about procedures that are common but unneeded, and encouraging both to discuss their necessity and effectiveness before they’re performed.

That’s what Choosing Wisely does. An initiative of the American Board of Internal Medicine Foundation and Consumer Reports, the campaign provides data and guidelines for doctors and patients. Choosing Wisely asks medical boards and societies to identify commonly used procedures whose necessity should be questioned and discussed, and then to issue their findings in bulletins entitled “Things Providers and Patients Should Question.”

The aim is to promote dialogue and urge patients to only have tests or treatments that are: supported by evidence; don’t duplicate other tests or procedures they’ve had; and that are necessary and free from harm. At the time of this writing, dozens of medical specialty boards representing thousands of physicians have made 490 recommendations related to overused medical tests, treatments, and drugs.

Be sure you are informed of the results of tests, exams, and treatment.

Ask when test results will be available, and how you’ll be informed of them. Doctors increasingly rely on electronic medical records to manage cases and, ideally, allow patients secure access to their test results. But many doctors still call patients with results, and some do so only if there is a problem. That approach may leave you wondering long after your doctor has the answers.

Discuss the results of tests and exams.

Ask the doctor to compare findings from new tests and exams to previous ones, and ask whether you can make changes in your life to improve results.

Prepare for appointments.

Before a doctor’s visit—either a visit to a doctor’s office or a visit by the doctor when you are in the hospital—get ready. Make a list of your symptoms, questions you want answered, and what treatments you’ve been giving yourself or that other providers have been giving you. Write it all down. If you take several medications, take them with you.

If the doctor rushes you through your questions, explain that discussing these matters is important to you, and that you want the doctor to give you enough time. Take notes. Consider having a family member or friend accompany you to help ask your questions and remember the responses.

Describe symptoms in detail.

Does the problem occur only after you’ve eaten, after you’ve exercised, when you’ve been standing for a long time, when you urinate? What does it feel like? When did you first notice the problem? Your description is a window to what’s going on inside—often a better window than all the examining and testing the doctor can do.

If you suspect that you might have a particular medical condition, tell the doctor. This will give the doctor a chance to investigate those concerns or assure you that they are unfounded.

Ask for a full explanation of your diagnosis, treatment options, and outlook for recovery.

Get a full explanation of what your doctor discovered from your exam and tests, your choices, and what you can expect. What isn’t working right? What caused it? What can be done about it now? If it’s curable, what can you do differently to avoid a recurrence—for example, change your eating habits, exercise differently, sleep differently, sit differently, change jobs, wear a brace?

How sure is the doctor of the diagnosis? What are other possibilities? What more can be done to confirm the diagnosis? At what cost and what risk?

What are the treatment options? What are the risks and costs? What are the possible benefits in terms of your lifestyle and ability to function? How will you know if the treatment is working? What will you need to report to the doctor?

One of your fundamental rights as a patient is the right to informed consent. If you agree to a treatment—to allow a doctor to act on you with drugs, knives, or other instruments—that you would not have chosen had you better understood your options, the doctor’s actions really amount to an assault. That’s why responsible doctors understand the importance of answering all your questions.

Ask about referrals to specialists.

If your doctor refers you to a specialist, ask why a specialist is needed and why that particular specialist was chosen. What is known about the specialist’s expertise and experience with your type of case? Is this the only specialist of this type that your primary doctor can refer you to under his or her arrangements with your health plan? Ask the doctor to compare the specialist to whom you are referred to other specialists listed here at Checkbook.org.

What should you expect the specialist to do? How will your primary care doctor remain involved in your care?

If you are not referred to a specialist, ask why not. What extra expertise might a specialist bring to the case?

Ask about medication.

If a medication is recommended, ask why the doctor chose that particular medication. What are its benefits? How soon will it work? What are possible side effects, and what should you do if you experience them? How should you take the medication—for example, with meals? At bedtime? Can you take it even though you’re taking other medications? What should you do if you forget to take a dose? Will the medication limit your capacity to drive, work, or participate in other activities?

Medical websites also provide extensive information on drugs—what they are used for, possible side effects, interactions, etc. A very useful site is MedlinePlus.

Ask about hospitalization.

If hospitalization is not recommended, ask why not. Hospital stays are expensive and health insurance plans want to cut costs. If a plan pays its doctors by an arrangement that gives them less income when patients are hospitalized, make sure financial incentives are not causing you to receive inadequate care.

On the other hand, if hospitalization is recommended, ask why. Could the case be handled on an outpatient basis?

Hospitals are dangerous places. Preventable medical errors of various kinds kill at least 200,000 Americans each year, making it the third leading cause of death in the United States—six times as many deaths as auto accidents. And there are many additional cases where hospital or doctor negligence slows recovery or leads to short-term or long-term disability. Even where there are no errors, infections and other problems can occur.

Checkbook provides ratings of U.S. hospitals, based on comparisons of death and adverse outcome rates for major types of cases; doctors’ ratings of hospitals in areas such as high-risk adult surgery, low-risk adult surgery, high-risk child surgery, complex medical care for adults, and maternity care; assessments of whether hospitals fail to provide proper tests and procedures; patient ratings; and how hospitals performed on key patient safety measures.

If you need hospitalization or an outpatient procedure, ask why a particular facility is chosen. Is it the only hospital to which the doctor refers patients or can work at?

How complicated is your case? Does it require sophisticated hospital staff or advanced equipment? What are the risks of complications? Will it be important to have close monitoring and quick access to medical staff and equipment at all times? If the case is complicated, a major teaching hospital might be best.

Is your required treatment one for which special training or frequent experience is important? Are there certain hospitals where the staffs have more skill, more experience, or higher success rates than others with this treatment? In many types of cases—such as open heart surgery—research has shown that hospitals that treat a greater number of patients generally produce better results.

Get second opinions.

If your doctor recommends hospitalization or other treatment that is expensive, risky, or burdensome, get a second opinion. In such cases, most doctors will welcome second opinions. And most insurance plans will be glad to pay, since the second opinion may lead to a recommendation of less care—and lower costs.

If possible, get your second opinion from an entirely independent doctor. If a surgeon who has recommended surgery refers you to another surgeon for a second opinion, the second doctor might find it difficult to recommend against the advice (and the economic interests) of the first. Our ratings of doctors will help you identify one to consult for a second opinion. Also, if you read up on your type of case—especially if it is being actively researched at certain medical centers—you may come upon names of leading specialists who might be available for advice.

To limit the cost and time required for a second opinion, have your first doctor send copies of your medical records, X-rays, and lab results to the second-opinion doctor. This is standard procedure.

Don’t assume that because yours is a straightforward, uncomplicated case there is nothing to learn and no decisions to be made. In most cases, there are choices.

This point is brought home by studies performed by Dartmouth Medical School researchers and others who looked at variations in medical practice in common types of cases across similar geographic areas. One of these studies found, for example, that about 75 percent of the elderly men in one Maine town had undergone prostate surgery, compared with fewer than 25 percent of men the same age in an adjacent town. Similar variations have been found in rates of hysterectomies, caesarean sections, and other common procedures. Significantly, studies generally find no evidence that such medical practice differences result in differences in the health status of the affected populations.

The implication is that big differences in the ways patients are treated result from differences in the beliefs and customs of different physicians in different communities—possibly influenced by the need to generate fees and not necessarily based on sound evidence of likely benefits to the patient. Even in a common type of case, don’t assume that a physician’s standard recommendation is the best option for you.

If the first and second opinions are in conflict, or for some other reason you still lack confidence in the conclusions, insist on a third opinion.